RUPTURE OF THE SPLEEN

1. RUPTURE OF THE SPLEEN

2. AETIOLOGY
• The spleen is the most common intra-abdominal
organ injured in blunt trauma.
• Only occasionally there may be spontaneous
rupture.
In majority of cases rupture of the spleen occurs
from
• 1.penetrating trauma,
• 2.nonpenetrating trauma
• 3.operative trauma.
• 4. Spontaneous Rupture

3. 1.Penetrating Trauma
• Gun-shot wounds, missiles and stabings may
cause splenic rupture.
• The penetration may occur through the
anterior abdominal wall, through the flank or
trans-thoracically piercing the pleural space,
the lung and the diaphragm.
• Surrounding organs may be injured, of which
the stomach, the left kidney, the pancreas and
the root of the mesentery are important.

4. 2. Non-penetrating Trauma.
• Automobile accidents, bicycle injuries, blows
and during various contact sports injury to
the spleen may occur.
• In blunt trauma other organs besides spleen
may be injured, of which the liver, the kidneys,
the chest (rib fractures), the lungs, the small
intestine, the colon and the stomach are
important.

5. 3. Operative Trauma.
• Spleen is injured in about 2% of operations
involving viscera of the left upper quadrant
• Injury may also occur from retractors placed
against this organ to get exposure to the
depth in various operations.

6. 4. Spontaneous Rupture
• Spontaneous ruptures may only occur when the spleen
is pathologic.
• Such rupture may occur from minor trauma.
• Spleen ruptures more easily when it is enlarged in
infectious mononucleosis or malaria.
• In infectious mononucleosis, this complication occurs
most frequently in the 2nd to 4th weeks of the disease.
• In other pathologic conditions also splenic rupture has
been reported e.g. sarcoidosis, acute and chronic
leukaemia, congestive splenomegaly, haemolytic
anaemia and polycythemia vera.

7. PATHOLOGY.
• Splenic injuries vary from simple transverse tear
of the parenchyma to transverse crack of the
hilus.
• There may be subcapsular haematomas only in
minor cases or there may be complete disruption
of the organ and its vessels in the fulminating
injuries.
• Majority of the injuries result in transverse
rupture of the parenchyma, the direction of
rupture is determined by the internal architecture
of the organ which is arranged in transverse
fashion in spleen.

8. Mainly 3 types of rupture are seen in spleen
1. ACUTE RUPTURE
2. DELAYED RUPTURE
3. OCCULT SPLENIC RUPTURE

9. 1. ACUTE RUPTURE
• Which occurs mostly due to blunt trauma and is
featured by immediate intraperitonealbleeding.
• In this variety two types are seen —
• In one type the patient succumbs rapidly giving
no chance to initiate proper treatment. In the
• 2nd type there is initial shock, from where the
patient recovers by treatment revealing signs of
ruptured spleen.
• Fortunately the 2nd type is much more common.

10. 2. DELAYED RUPTURE
• In this type after an interval of a few days to weeks after
injury, sudden intraperitoneal bleeding starts.
• This delayed rupture is reported in 10 to 15% of the cases
of blunt trauma.
• In about half of these cases bleeding occurs within 7 days
and in 75% of cases bleeding starts within 2 weeks of the
accident.
Such delayed type of rupture is probably due to
• (a) blood clot, temporarily sealing the rent, becomes lysed
by the enzymes of the lacerated tail of the pancreas;
• (b) slowly enlarging subcapsular haematoma which
eventually ruptures or
• (c) the greater omentum, which shuts off the injured site
initially, gradually moves off.

11. 3. OCCULT SPLENIC RUPTURE
• The term is applied when traumatic
pseudocyst of the spleen is diagnosed though
injury to the organ previously has not been
diagnosed.
• This type is seen in less than 1% of patients
sustaining injury to the spleen.
• It is caused by organisation of intrasplenic or
parasplenic haematoma.

12. • Another condition related to splenic injury is
known as splenosis.
• It is due to autotransplantation of fragments
of ruptured spleen on to the peritoneal
surface.
• This condition is usually asymptomatic, but
patients may present with intestinal
obstruction later on due to adhesions.

13. CLINICAL FEATURES
• The clinical course of an isolated splenic injury is
variable depending on severity and rapidity of
intra-abdominal haemorrhage.
• Laceration through the body of the spleen can
extend into the splenic pedicle causing extensive
and continued haemorrhage with
haemoperitoneum and acute shock.
• An adhesion between the spleen and its
ligaments or diaphragm may seal the capsular
avulsion with cessation of haemorrhage after an
initial blood loss of not more than 500 ml.

14. • If injury is limited to the capsule or pulp and
does not involve the major splenic
vasculature, the patient may remain
haemodynamically stable.
• However subcapsular haematomas have
potentiality to rupture later producing
‘delayed rupture’ of the spleen.

15. • If a splenic injury is suspected, admission to
the hospital for monitoring is mandatory.
• A careful history should be obtained regarding
mechanism of the injury.
• Injury to the left upper abdomen, more so
with associatedb fractured ribs, may cause
injury to spleen.

16. • The signs and symptoms of injury to the
spleen depend on severity and rapidity of
intra-abdom inal haemorrhage, as also on
presence of other organ injuries.

17. • (i) Some degree of shock due to
hypovolaemia, characterised by tachycardia,
low blood pressure, restlessness, increasing
pallor and sighing respiration may be seen in
majority of cases.
• (ii) Local bruising and tenderness in the left
upper quadrant of the abdomen is often seen.
• (iii) Patient usually complains of generalised
upper abdominal pain, which in 1/3 rd of the
cases is localised to the upper left quadrant.

18. • (iv) Pain may be referred to the tip of the left
shoulder, which is known as Kehr’s sign.
• Kehr’s sign can be elicited by bimanual
compression of the left upper quadrant after the
patient has been in Trendelenburg’s position for
about 10 minutes prior to the manoeuvre.
• There may be hyperaesthesia on the left
shoulder.
• Kehr’s sign is due to irritation of the undersurface
of the diaphragm with blood and the pain is
referred to the shoulder through the affected
fibres of the phrenic nerve (C4 and C5).

20. • (v) On rare occasions a palpable tender mass
can be felt in the left upper quadrant with
persistent dullness.
• This is known as Ballance’s sign.
• This sign is due to extracapsular or
subcapsular haematoma which is guarded by
omentum or by early coagulation of splenic
blood.

21. • (vi) Tenderness and rigidity of the left upper
quadrant is a frequent and reliable physical
sign.
• (vii) Shifting dullness may be detected on the
right side due to intraperitoneal haemorrhage.
• (viii) Diagnostic peritoneal lavage is a useful
and inexpensive manoeuvre which may reveal
intraperitoneal haemorrhage.

22. Special Investigations
• 1. Haematocrit value may be reduced if there
is major bleeding, but initial readings may be
normal.
• Increase in W.B.C. count (moderate
leukocytosis) is noticed in many cases.
• 2. Routine STRAIGHT X-RAY of the abdomen
often gives confirmatory evidence regarding
diagnosis.

23. • This investigation is extremely helpful in
places where sophisticated investigations are
not possible. The probable findings in X-ray in
case of splenic rupture are:—

24. • (a) Obliteration of the splenic outline,
• (b) An enlarged splenic shadow,
• (c) Obliteration of the psoas shadow,
• (d) Indentation of the left side of the gastric
shadow,
• (e) Widening of the space between the splenic
flexure and the properitoneal pad of fat.
• (f) Elevation of the left side of the diaphragm,
• (g) Free fluid between gas filled intestinal coils,
• (h) Fracture of one or more lower ribs on the left
side. A normal well outlined spleen indicates
intact spleen on straight X-ray.

25. • 3. SPLENIC ANGIOGRAPHY
• 4. ULTRASONOGRAPHY
• 5. ISOTOPE SCANS
• 6. CT SCAN

26. • TREATMENT
• Immediate laparotomy and splenectomy is the
life saving procedure and is still the standard
treatment.

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